What Should I Do About Acid Reflux During Chemotherapy?

How cancer treatment can trigger reflux and what you can do about it

AMBULATORY CHEMOTHERAPY
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If you're going through chemotherapy, you may already be familiar with the gastrointestinal effects of these potent medications—acid reflux, indigestion, and heartburn—which can flare up after meals, during normal activity, or at night when you're trying to sleep. You may be wondering why you're experiencing these symptoms and how long the symptoms will last after your chemo has completed. Before you reach for the Tums or other acid-blocking medications, read on to find out why acid reflux occurs and what you can do about it.

What Exactly Is Acid Reflux?

Acid reflux is a digestive condition in which stomach acid or bile flows upward from the stomach into the esophagus resulting in irritation. The irritation can be in the throat or chest, which commonly presents as heartburn. Symptoms can also include a sore throat or lump in the throat, coughing, sour or bitter taste in the mouth, indigestion, difficulty swallowing, and asthma-like symptoms. It's thought that up to 30% of people in the U.S. experience acid reflux, and it affects all age groups and ethnicities.

Why Chemotherapy Increases Acid Reflux

Acid reflux can be common both while undergoing chemotherapy and after treatment has ended. That's because chemotherapy drugs work by targeting rapidly dividing cells, including the cells in the lining of the stomach and digestive tract, which protect the digestive organs from corrosive stomach acid. Chemotherapy drugs simply cannot tell the difference between these normal, rapidly dividing cells and cancer cells, so the drug attacks these cells as well. The result can present as irritation in the stomach, esophagus, and throat from an increased susceptibility to stomach acid.

Other Causes of Acid Reflux

In healthy individuals, it is commonly thought that acid reflux is caused by an abundance of stomach acid, but that is not always the case. Contrary to popular belief, acid reflux is often a result of not having enough stomach acid and/or digestive enzymes to efficiently break down a meal. Certain foods, beverages, and over-eating can contribute to the problem. If you were experiencing acid reflux prior to undergoing chemotherapy treatment, it might be due to those potential causes. Other causes include:

  • Being overweight, obese, or pregnant which puts pressure on the abdomen.
  • Taking certain medications like aspirin, ibuprofen, muscle relaxers, blood pressure medications, anti-depressants, etc.
  • Taking OTC medications and proton-pump inhibitors (PPI) to control acid reflux, which can have a boomerang effect, especially if the condition is due to low stomach acid.
  • Having a stomach infection with the helicobacter pylori bacteria, which can either increase or neutralizes stomach acid. H. pylori is thought to infect 50% of people.
  • A structural abnormality called a hiatal hernia.

Hiatal hernias are thought to affect up to 60% of people over age 50. That can be a common cause of acid reflux in this age group, combined with less stomach acid which decreases as we age.

Normally, the diaphragm separates the chest cavity from the abdomen, and helps keep acid in the stomach, but with a hiatal hernia, the top part of the stomach pushes through the normal opening of the diaphragm into the chest cavity. Without a strong barrier between the stomach and the esophagus, acid can then move up into the esophagus and cause symptoms of acid reflux.

Anyone can get a hiatal hernia, since it is caused by excess pressure in the abdomen, but they happen most commonly in people who smoke, are overweight, or individuals older than 50.

When Experiencing Acid Reflux It's Best to Avoid

Whether you're currently undergoing chemotherapy or you've completed your treatment and are experiencing acid reflux, it's a good idea to avoid the following to lessen the likelihood of experiencing discomfort.

  • Eating large meals
  • Lying down or bending over at the waist right after a meal
  • Snacking close to bedtime
  • Eating certain acidic foods such as citrus, tomato, chocolate, mint, garlic, onions or spicy or fatty foods
  • Eating foods that are hard to digest such as animal protein and dairy, especially late in the day
  • Drinking certain beverages, such as alcohol, carbonated drinks, coffee, or tea
  • Smoking
  • Wearing tight clothing or belts

Try to keep a symptom record to determine if a certain food or activity triggers your acid reflux. Some people find fried foods or carbonated beverages cause or worsen acid reflux, but they can eat dairy or citrus without an issue. Keeping track of when it occurs can help you to eliminate foods or other things that exacerbate your symptoms.

If you have special nutrition considerations as a result of your chemotherapy treatment, you should talk to your doctor or a registered dietician to ensure you're getting the right nutrients and enough calories.

Treatment Options

Taking digestive enzymes as well as increasing stomach acid with betaine hydrochloric acid (HCL) tablets found at health food stores may be all that's needed to relieve acid reflux for some healthy individuals; however special considerations should be taken for those undergoing chemotherapy treatment due to the increased digestive sensitivity caused by chemotherapy.

Other typical courses of treatment for acid reflux may include over-the-counter (OTC) or prescription acid-neutralizing or acid-blocking medications. These come with their own risks due to possible drug interactions with certain types of chemotherapy and other prescription medications. That's why it's always a good idea to talk to your doctor about all of the medications you're taking concurrent with your chemotherapy and discuss any new medications before starting. Some common medications for acid reflux include:

  • OTC antacids like Tums, Rolaids, and Mylanta.
  • OTC or prescription proton-pump inhibitors (PPIs) like Nexium 24h (esomeprazole), Prilosec (omeprazole magnesium), Prevacid 24h (lansoprazole), Zegerid (omeprazole and sodium bicarbonate).
  • OTC or prescription H2 blockers like Pepcid Complete or Pepcid AC (famotidine), Tagamet HB (cimetidine), Axid AR (nizatidine), Zantac (ranitidine).

Antacids function by neutralizing stomach acid with a relatively benign mix of compounds including calcium carbonate, magnesium hydroxide, aluminum hydroxide, and/or sodium bicarbonate, also known as baking soda. They are useful for occasional relief of acid reflux symptoms. Despite the relative safety of their ingredients, they should not be taken in excess of the dosing recommendations on the label or with certain types of chemotherapy due to possible neutralizing effects on chemotherapy and other drug interactions. Long-term use can result in potential adverse health outcomes, especially for people who have high blood pressure, renal failure, or a risk of osteoporosis, according to the International Foundation for Gastrointestinal Disorders.

PPIs and H2 blockers work a bit differently than antacids by decreasing the stomach's production of acid. Special considerations should be heeded for people undergoing chemotherapy who may take these medications. One study showed an increase survival rate for patients with a certain type of head and neck cancer who take PPIs and H2 blockers, while another study showed a decrease in survival rate for people with gastroesophageal cancer when taking PPIs and potentially H2 blockers because of the medicine's neutralizing effects on certain types of chemotherapy.

PPIs and H2 blockers should only be used for a short period of time in healthy individuals, and presumably also in people undergoing chemo unless otherwise directed by a physician. Side effects of prolonged use may include cancer, osteoporosis, decreased stomach acid (hypochlorhydria), reduced nutrient absorption (malabsorption), increased risk of infection, as well as an increased risk of dementia, kidney disease, and death in long-term PPI users.

The Bottom Line

Some people may be able to alleviate their acid reflux naturally without medication by introducing lifestyle changes, new eating habits, and by implementing some interventional measures like elevating the head of their beds so they're lying on an incline. Eating a handful of small meals throughout the day rather than several large meals may also help relieve acid reflux. Because certain foods can aggravate this condition, it's worth keeping a log of offending foods and finding alternatives to those items while still maintaining a nutritionally balanced diet.

If lifestyle changes to prevent your acid reflux are not enough, seek medical advice from your primary care provider and a licensed nutritionist knowledgeable about chemotherapy and digestive disorders before beginning any medication.

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  2. Xie Y, Bowe B, Li T, et al. Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans. BMJ Open 2017;7:e015735. doi: 10.1136/bmjopen-2016-015735

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